CONSENSUS WORKSHOP SESSIONS
Development of the Capacity Necessary to Perform and Promote Knowledge Translation Research in Emergency Medicine Peter S. Dayan, MD, MSc, Martin Osmond, MD, CM, Nathan Kuppermann, MD, MPH, Eddy Lang, MD, Terry Klassen, MD, MSc, David Johnson, MD, Sharon Strauss, MD, Erik Hess, MD, Sandra Schneider, MD, Marc Afilalo, MD, Martin Pusic, MD, MA
Abstract Knowledge translation (KT) research in emergency medicine (EM) is in its infancy, and few EM investigators have the skills needed to perform KT research. Furthermore, the capacity to perform such KT research is underdeveloped in the field of EM. This consensus group used an iterative process to set forth initial recommendations and suggest methods for the development of EM KT research capacity. We have emphasized the need to form sustainable linkages, particularly between EM researchers and KT scientists, and to educate EM researchers in KT research methods to help create and sustain a culture of KT in our field. EM KT researchers must also engage local and national organizations and stakeholders to fund and promote KT research. Finally, we see the need to further develop and support EM research networks, as these networks will be both the clinical laboratories in which to perform the KT research and the incubators for the development of EM KT research experts. ACADEMIC EMERGENCY MEDICINE 2007; 14:978–983 ª 2007 by the Society for Academic Emergency Medicine Keywords: knowledge translation, capacity, network, emergency medicine
s the clinical evidence base increases, we must build a robust and sustainable capacity to perform research in knowledge translation (KT) in the field of emergency medicine (EM). Without EM KT research capacity, we risk widening the gap between what we know and what we practice in caring for acutely ill and injured patients. Although variably defined, research capacity results from the garnering of intellectual, human, and financial resources. Capacity building in KT research involves many processes, including educating and organizing researchers so that they can collectively investigate ways to increase the effectiveness of medical
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research to change health policy and improve patient outcomes. Capacity building also involves initiatives that engage and stimulate interest from organizations, agencies, and other stakeholders that will support and fund KT research initiatives.1–3 In addition to financial resources, successful capacity building that will enhance our ability to perform EM KT research requires the development of EM researchers with sustainable skills and the development of relationships between these researchers and 1) individual practitioners (i.e., end-users of EM KT research); 2) institutions that will support and benefit from KT research; 3) regional,
From the Department of Pediatrics, The Morgan Stanley Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians & Surgeons (PSD, MP), New York, NY; Departments of Pediatrics and Emergency Medicine, University of Ottawa (MO), Ottawa, Ontario, Canada; Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine (NK), Davis, CA; Department of Emergency Medicine, Sir Mortimer B. Davis Jewish General Hospital, McGill University (EL, MA), Montre´al, Que´bec, Canada; Department of Pediatrics, University of Alberta (TK), Edmonton, Alberta, Canada; Department of Pediatrics (DJ) and Department of Medicine (SSt), University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Toronto (SSt),
Toronto, Ontario, Canada; Canadian Institutes of Health Research (SSt), Toronto, Ontario, Canada; Department of Emergency Medicine, University of Ottawa (EH), Ottawa, Ontario, Canada; Department of Emergency Medicine, University of Rochester (SSc), Rochester, NY. Received June 14, 2007; accepted June 15, 2007. This is a proceeding from a workshop session of the 2007 Academic Emergency Medicine Consensus Conference, ‘‘Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake,’’ Chicago, IL, May 15, 2007. Contact for correspondence and reprints: Peter S. Dayan, MD, MSc; e-mail:
[email protected].
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ISSN 1069-6563 PII ISSN 1069-6563583
ª 2007 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2007.06.033
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national, and international collaborations, organizations, institutes, and agencies that will fund the research; and 4) the private sector.4,5 The need for building EM KT research capacity coincides with increasing KT funding opportunities such as through the Agency for Healthcare Research and Quality Translation Into Practice program, the Canadian Institute of Health Research (CIHR) Knowledge Translation initiatives, and the National Institutes of Health (NIH) Clinical Translation Science Awards (CTSA).4–7 The aim of this document is to make recommendations in response to the question, ‘‘What approaches should be emphasized in order to develop capacity that will promote KT research in EM?’’ The recommendations provided in this document are the result of an iterative process among the authors, who include several EM researchers with leadership positions in multicenter clinical research networks and researchers with experience in KT design and methodology. Due to the particular makeup of the author group, our recommendations mainly reflect Canadian and U.S. perspectives with our respective health systems organizations. We recognize and acknowledge other substantial international KT research efforts, such as those in Australia, the United Kingdom, and elsewhere.8,9 Where appropriate in the recommendations and rationales that support these recommendations, we address the levels at which research capacity must be developed and integrated within specific categories of KT research. These categories of KT research are illustrated in the ‘‘KT loop’’ (Figure 1) adapted from Tugwell et al.10 by the
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Pediatric Emergency Research Canada multicenter research network. This KT loop includes research on the barriers to knowledge transfer and uptake, studies to determine the effectiveness of different KT strategies, assessment of the impact on clinical outcomes of active dissemination and implementation approaches, and measurement of the effect of evidence diffusion on health outcomes. We view our recommendations as initial steps in the development of capacity of KT research in EM. As EM KT research evolves and capacity grows, we recognize the need to update and potentially expand these recommendations.
RECOMMENDATIONS AND RATIONALES Recommendation 1: Development of Partnerships and Linkages among EM and KT Investigators Because EM KT research is in its infancy, few EM investigators have developed the skills needed to perform KT research. As one initial step, we recommend the formation of partnerships and linkages among EM clinical researchers, researchers with specific areas of expertise relevant to KT research, and KT centers of excellence to appropriately design, implement, and analyze KT studies for EM. Rationale Each category of KT research often requires study designs and methodologies that need specific expertise
Figure 1. Research paradigm: the iterative figure-eight. SR = systematic review; KT = knowledge translation; RCT = randomized controlled trail. Adapted from Tugwell et al.10
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about which EM investigators have little education and experience. This expertise includes but is not limited to 1) qualitative study methodology such as focus groups, surveys, and in-depth interviews to study barriers and enablers to evidence uptake11,12 and 2) quantitative study methodology such as cluster randomized controlled trials and interrupted time series trials to study the effectiveness of KT interventions.13–16 Deficiencies in the design and analysis of prior KT research efforts15 highlight the group’s strong recommendation that an initial aim of capacity development should be to form linkages and use existing resources to develop and perform these KT studies. Specific resources would include 1) established KT researchers with expertise in quantitative and qualitative study design and methodology; 2) statisticians with KT research experience; 3) behavioral and social scientists to help study the interpersonal, interprofessional, and cultural barriers and facilitators to evidence uptake; 4) cognitive psychologists to help examine the thought processes involved in clinical reasoning and decisionmaking; 5) information technologists/computer scientists to assist with the design of point-of-care decision support tools; and 6) KT research centers where the resources listed previously and other resources would likely be accessible.17,18 The formation of partnerships and linkages will consolidate resources among individual scientists, research groups, and research centers that have differing but potentially synergistic areas of expertise. These linkages would allow for local groups to have particular areas of expertise, such as in decision support tool development, implementation strategies, and evaluation methods, but not require the development of all areas of expertise in each group or at each center. These linkages will have the added benefit of generating expertise within the ranks of EM researchers. Potential methods to meet this recommendation include: organizing local and national colloquia that bring together EM clinical researchers and KT scientists. There is likely support and interest in this from organizations such as the Agency for Healthcare Research and Quality, CIHR, and NIH. engaging scientists with specific areas of KT expertise to participate in EM research network studies, potentially with the provision of grant support or through consultation agreements. identifying and becoming involved in ongoing efforts, such as the CTSA initiative, to connect researchers who, even within their own institution, have little knowledge of available KT resources or KT investigators’ fields of study and areas of expertise. Recommendation 2: Promotion of Education of EM Researchers in KT Methodology Long-term growth and sustainability of KT research within EM will ultimately require the aggressive development of investigators capable of becoming independent, grant-funded EM scientists with KT research expertise. Toward this end, we recommend the formal incorporation of KT research design and methodology education
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into all levels of existing EM research training and the development of EM research fellowships and funding programs with a specific focus on KT. Rationale KT in general is a distinct science that has its own fundamental theories and research methods that do not directly overlap the knowledge and skill sets of even the most accomplished clinical EM researchers. The training in KT would by necessity be multidisciplinary, with instructors from the realms of behavioral science, psychology, computational science, and medical informatics. The training of EM researchers in KT should be of two types: 1) training of all EM researchers with curricula that include information regarding the importance of KT and instruction on how to use KT techniques in EM research and 2) more specific training for EM researchers whose main focus will be on KT research. In regard to the first type, research training in EM will have to emphasize the KT potential of clinical and health services research projects. An important aspect of this is developing a culture within the EM research community wherein the KT potential of EM research is recognized from the outset and incorporated into the design of appropriate EM studies. In regard to fostering the development of EM KT research specialists, it is clear that KT in EM has unique challenges compared with KT in other domains in medicine. The practice of EM is ‘‘decision dense,’’ making it an ideal laboratory for examining the influence of new knowledge on clinical decision-making. These questions warrant the training of independent investigators whose research careers would be devoted to EM KT, specifically the study of the application of KT theories and methods specific to EM. At least initially, these specialists could be either 1) emergency physicians who train in KT programs or 2) master’s level or PhD scientists in KT who are employed in EM research centers. These specialists/scientists may have specific expertise in behavioral medicine, computation/information sciences, or other domains pertinent to KT research. These specialists would make research contributions to both EM KT and KT as a field, in general. To meet this recommendation, we propose that: all EM researchers receive formal training in the theories and methods of KT research with the development of standard curricula that foster an EM KT culture. EM research fellowships include a strong KT component with the development over time of funded fellowships in EM KT for promising investigators. federal and other funders recognize the importance of KT research in EM through the establishment of specific start-up funds and the selection of career-development awardees (e.g., through NIH-sponsored K23 and K12 awards and Emergency Medicine Foundation career development and research fellowship grants).19 The NIH CTSA program presents exciting opportunities in this regard.7
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Recommendation 3: Development and Expansion of KT in EM Research Networks EM research networks that include a diversity of emergency department (ED) environments are a key component of the capacity to perform definitive, generalizable studies in all categories of KT research. Although the number of EM research networks in North America has increased in recent years,20–22 these networks are variably funded and have only recently started to engage in KT research. Therefore, we strongly recommend the continued development and expansion of national and international EM research networks and that, within these networks, emphasis is placed on KT research, including the explicit consideration of subsequent KT in the design of appropriate studies, particularly state-of-the-art, likely definitive clinical trials. Rationale KT research must be generalizable. Prior KT research has often been performed at individual sites, among a limited number of centers, or among similar types of centers such as academic institutions. To produce generalizable results, KT research in EM must be performed at multiple EDs with different characteristics (e.g., community, teaching, pediatric, and rural, urban, and suburban EDs). Definitive KT research will require large sample studies and designs that mandate multiple centers. An example of this design is a cluster randomized implementation trial conducted by Stiell et al. in the implementation of the Canadian C-spine rule.13 EM research networks with sustained funding for investigators, full-time research coordinators and assistants, and data management and statistical personnel enable the conduct of multiple large KT studies at lower overall cost due to economies of scale. Funded, stable, and robust research networks that include large numbers of centers with disparate characteristics would allow, for example, the performance of more than one KT cluster randomized trial at a time. These large networks can choose which centers are or are not appropriate, or necessary, for a particular KT initiative. Additionally, the development of successful working relationships within the network minimizes study start-up costs and time and increases the likelihood of successful KT study completion. Networks often perform large-scale definitive cohort studies (such as validations of diagnostic prediction rules) and clinical trials to test the efficacy of an intervention without assessing the issues related to translating this new knowledge into practice. This represents a lost opportunity. The researchers could gain invaluable information by explicitly and simultaneously assessing issues related to the adoption of study results in the ED setting. Networks are potentially attractive to established KT researchers as fertile environments in which to conduct definitive KT research. Because established KT scientists and other key research partners (as detailed in recommendation 1) are likely to be overextended, we must provide incentive for them to partner with EM researchers. Multicenter EM research networks
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that provide administrative infrastructure and resources, established EM researchers, dedicated sites, and a track record of successful funding are such strong incentives. As EM networks become more proficient in KT research, we must illustrate to institutional administrative leadership the benefits of participating in the networks. These include faculty funding, department and faculty development, prestige, and, most importantly, the ability of EM KT research to improve patient care. It could be emphasized that simply participating in EM KT research in and of itself often results in improved care. Leaders in EM research must continue to advocate for network development, including securing infrastructure funding. Government agencies such as the Emergency Medical Services for Children have recognized this need, providing crucial support for network infrastructure.21 CIHR has recently awarded a team grant that provides network infrastructure funds with a specific focus on the conduct of KT research.22 Finally, we must encourage networks to view EM KT research as a priority. We strongly encourage network researchers to include a KT dimension within proposals and grants directed at evidence generation (e.g., clinical trials on efficacy). In this way, questions related to barriers, facilitators, dissemination, and implementation can be partially addressed and future KT studies can be designed. KT initiatives would then immediately follow and result as a direct outgrowth of definitive network studies such as large clinical trials of efficacy. EM networks, linked to KT researchers, should become the experts in EM KT, where each study and trial will inform subsequent KT research and thus the science of KT can be advanced as the clinical evidence base grows. Recommendation 4: Development of Linkages and Partnerships between EM KT Researchers, Emergency Clinicians, EM KT Champions, and Health Care Organizations Although we have emphasized relationships among, and training of, individuals who perform EM KT research, considerable EM KT work is performed by clinical champions who are not researchers. Examples of such work include local guideline development, evidencebased quality improvement initiatives, and national media awareness campaigns. The present lack of collaboration between EM KT researchers, evidence end-users, and those intimately involved in KT work at the local and national levels is a missed opportunity to create ownership by all essential parties who could be instrumental both in developing the research and facilitating the use of research findings after study completion.23,24 We therefore strongly recommend linkages and partnerships between EM KT researchers and 1) health care providers, 2) local EM KT champions, 3) local health care organizations such as academic health centers, and 4) regional and national organizations. Rationale Relationship with Emergency Clinicians. Bidirectional communication and links between EM KT researchers
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and health care practitioners, who do not necessarily participate in academic research, are essential to study and promote methods that will be more readily accepted by end-users once demonstrated to be effective. Emergency clinicians are best placed to help generate research questions that give us insight into the barriers facing EM KT and potential solutions to the barriers. Relationship of EM KT Researchers to Local EM KT Champions and Health Care Organizations. EM KT champions, such as those involved in promoting guideline implementation and clinical pathways, often ally with local health care organizations such as academic health centers to develop, implement, and measure the effectiveness of KT initiatives.25 EM KT researchers should leverage these linkages. For example, an EM KT champion might be a clinician–leader who wishes to improve care by creating a best practices decision-support tool to implement a guideline. As part of this effort, she or he forms a multidisciplinary institutional team and partners with a local (or national) organization. An EM KT researcher could partner with the local KT champion and organization and measure process and patient-oriented outcomes directly relevant to the EM KT champion’s goals and organization’s mission. At the same time, this would generate new EM KT knowledge. These relationships would uncover real-world opportunities for KT research endeavors. Relationship of EM KT Researchers to Regional and National Organizations. A number of organizations are already engaged in KT activities relevant to EM at a national level.26 EM KT researchers could engage such organizations, emphasizing the need for rigorous evaluation of such efforts in the ED. Evaluation of KT interventions at a national level would be more readily accomplished by a research network. Therefore, a key partnership will be between EM research networks and national organizations. While organizations with a demonstrated interest in guideline development and dissemination would seem to be logical first points of contact, intriguing possibilities exist for collaborating with, for example, national patient advocacy groups or health information service providers.26 Potential methods to meet this recommendation include: identifying and partnering with those involved in KT at the local level, particularly those who are involved in multidisciplinary groups aimed at evidence implementation. strongly encouraging that researchers form, and funders mandate, investigative teams that include the recommended types of partnerships.23 establishing contact networks such as C.H.A.I.N. (Contact, Help, Advice, Information, Network), which was developed in the United Kingdom in 1997 and facilitates linkages between researchers and other health care professionals.27 promoting the inclusion of EM researchers with KT experience and expertise on committees that develop influential clinical guidelines. inviting national organization leaders to EM KT research network meetings and programs sponsored by EM organizations, such as the American College
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of Emergency Physicians and Society for Academic Emergency Medicine.
CONCLUSIONS, FURTHER DIRECTIONS, AND QUESTIONS In summary, in this document we have set forth initial recommendations and suggested methods for the development of EM KT research capacity. We have emphasized the need to form sustainable linkages, particularly between EM researchers and KT scientists, and to educate EM researchers in KT research methods to help create and sustain a culture of KT in our field. Finally, we see the need to further develop and support EM research networks, because these networks will be the clinical laboratories in which to perform, and incubators for the development of experts in EM KT research. We recognize that there are several areas we have not addressed and hope our efforts stimulate dialogue to answer many remaining questions, including the following: 1. What are other potentially feasible methods to establish and sustain linkages among researchers, clinicians, institutions and other health care organizations? 2. What constitutes the minimal KT research training for all EM investigators and an appropriate curriculum for EM researchers who will focus in KT? 3. Given relatively few EM mentors in KT research, how do we make KT research attractive and feasible as a focus for EM researchers? 4. How should EM research networks be best organized in order to foster KT research?28 5. How do EM research networks attract and maintain the large number of diverse institutions necessary to perform KT research? In addition to these questions that pertain to our recommendations, further consideration should be given to the relationships between the EM KT researchers and policy makers, the private sector (industry), and patients and their local communities. Finally, as part of this ongoing process, we must define the short-term and long-term measures of success in the development of EM KT research capacity. References 1. Crisp BR, Swerissen H, Duckett SJ. Four approaches to capacity building in health: consequences for measurement and accountability. Health Promotion Int. 2000; 15:99–107. 2. Cooke J. A framework to evaluate research capacity building in health care. BMC Fam Pract. 2005; 6:44. 3. North American Primary Care Research Group Committee on Building Research Capacity, and the Academic Family Medicine Organizations Research Subcommittee. What does it mean to build research capacity? Fam Med. 2002; 34:678–84. 4. Agency for Healthcare Research and Quality. Translating Research Into Practice (TRIP)-II. Fact Sheet. AHRQ Publication No. 01–P017. Available at: http:// www.ahrq.gov/research/trip2fac.htm. Accessed Jun 23, 2007.
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5. Agency for Healthcare Research and Quality. Evidencebased Practice Centers Overview. Available at: http:// www.ahrq.gov/clinic/epc/. Accessed Jun 23, 2007. 6. Canadian Institutes of Health Research. Knowledge Translation Strategy 2004-2009: Innovation in Action. Available at: http://www.cihr-irsc.gc.ca/e/26574.html. Accessed Jun 23, 2007. 7. National Center for Research Resources (NCRR), National Institutes of Health. Clinical and Translational Science Awards (Consortium). Available at: http:// ctsaweb.org/. Accessed Jun 23, 2007. 8. National Institutes of Clinical Studies. Annual Report 2005-2006. Available at: http://144.140.87.119/data/ portal/00000005/content/10410001167716155750.pdf. Accessed Jun 23, 2007. 9. National Health Services. The NHS Health Technology Assessment Programme. Available at: http:// www.hta.nhsweb.nhs.uk/. Accessed Jun 23, 2007. 10. Tugwell P, Bennett K, Sackett D, et al. The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions. J Chronic Dis. 1985; 38:339–51. 11. Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand CS. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med. 2000; 154:685–93. 12. Stiell IG, Brehaut JC. Clinical sensibility and barriers to knowledge translation. Ann Intern Med. 2006; 145: 77–8. 13. Stiell IG, Grimshaw J, Wells GA, et al. A matchedpair cluster design study protocol to evaluate implementation of the Canadian C-Spine rule in hospital emergency departments: phase III. Available at: http://www.implementationscience.com/content/2/1/4. Accessed Jun 23, 2007. 14. Thomas RE, Croal BL, Ramsay C, Eccles M, Grimshaw J. Effect of enhanced feedback and brief educational reminder messages on laboratory test requesting in primary care: cluster randomized trial. Lancet. 2006; 367:1990–6. 15. Ramsay CR, Matowe L, Grillo R, Grimshaw JM, Thomas RE. Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behavior change strategies. Int J Technol Assess Health Care. 2003; 19:613–23. 16. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination
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